应用胃上提和复合喉气管瓣重建下咽颈段食管癌切除后全周缺损163例临床分析

Application of gastric pull up and complex laryngotracheal flap to reconstruct the circumferencial defect after resection of the hypopharyngeal and cervical esophageal cancers

目的评价胃上提与复合喉气管瓣重建下咽颈段食管癌切除后全周缺损的临床作用。方法对1984年4月至2016年12月辽宁省肿瘤医院头颈外科的163例（男152例，女11例）下咽及颈段食管癌切除后形成的全周缺损，分别应用胃上提（42例）和复合喉气管瓣（121例）重建上消化道。115例同期行一侧颈清扫，20例行双侧颈清扫。术后接受放射治疗67例，总量40～60 Gy。Kaplan－Meier法进行生存分析，组间差异采用Log－rank法进行单因素分析。结果127例（77.9%）发现阳性转移淋巴结。42例胃上提重建上消化道的患者中，39例（92.8%）于术后恢复了经口进食功能，8例单纯胃食管吻合重建患者同时恢复了经口进食及发音呼吸功能。手术并发症死亡3例（7.14%），发生各种手术并发症8例。121例复合喉气管瓣重建上消化道手术全部成功，术后全部恢复了经口进食功能。无手术死亡患者，发生并发症24例，主要是咽皮肤瘘或创口感染，而且均经保守治愈。全组163例患者1，3，5年无疾病生存率分别为69.8%，50.5%和34.3%。Log－rank法分析影响预后的独立因素为T分期（P〈0.001），以及淋巴转移情况（P＝0.042）。结论复合胸大肌肌皮瓣喉气管瓣适合重建大多数晚期下咽癌切除后全周缺损，该技术操作简便，并发症发生率低且轻微，少数不适合应用胸大肌肌皮瓣者可用游离股前外侧皮瓣代替。胃上提实行胃咽吻合术重建上消化道适合大多数颈段食管癌及下咽癌侵犯到颈段食管而不适合复合喉气管瓣重建的病例。术后吞咽功能效果良好。但手术创伤较大，并发症凶险，在选择手术适应证时要慎重。

ObjectiveTo evaluate the efficacy of gastric pull-up and complex laryngotracheal flap in reconstruction for circumferencial defects after resection of hypopharyngeal and cervical esophageal cancers.MethodsA total of 163 cases （152 males, 11 females） with circumferencial defect after resection of hypopharyngeal and cervical esophageal cancers received reconstructive surgeries by gastric pull-up （42 cases） and complex laryngo-tracheal flaps （121 cases）, of them 115 cases simultaneously underwent unilateral neck dissection and 20 cases had bilateral neck dissection. Postoperative radiotherapy was used in 67 cases, with a dosage of 40-60 Gy.ResultsThere were 127 （77.9%） cases with positive metastatic lymph nodes. Of 42 patients with gastric pull-up reconstruction, 39 cases （92.8%） recovered the function of oral swallowing after operation, and 8 cases with cervical esophageal cancer recovered the functions of oral swallowing and speech after gastroesophageal anastomosis reconstruction. There were 3 （7.1%） cases died of surgery and 8 cases with surgical complications. Reconstruction of upper digestive tract with combined laryngotracheal flap was successful in all 121 cases, with recovered oral swallowing function after operation. No patient died of surgery but 24 cases had complications, mainly pharynx skin fistula or wound infection, which were cured by conservative treatments. The 1-, 3- and 5-year survival rates for 163 patients were 69.8%, 50.5% and 34.3%, respectively. The independent factors for prognosis included T4 （P〈0.001） and N＋ （P=0.042）.ConclusionsThe complex of laryngotracheal flap with pectoralis major myocutaneous flap is suitable for most advanced hypopharyngeal cancer after resection of the tumor and reconstruction of circumferencial defect. It is simple technology, low and slight complication rate. The minority is not suitable for the application of pectoralis major myocutaneous flap can be used instead of free anterolateral thigh flap. Gastric pull-up for reconstruction of upper digestive tract is suitable for most patients with cervical esophageal cancer and hypopharyngeal carcinoma invading the cervical esophagus who are not suitable for aryngotracheal flap reconstruction, with good swallowing function after surgery. However, it is prudent to choose operative indications because of serious surgical trauma and risks for complications.